I recently wrote about the difficulties I had getting an appointment with an ENT to fix a broken nose. I finally was able to see an ENT six days after breaking my nose. He came into the examination room with Michael, a medical student functioning as his assistant.

After a bit of chitchat about how I broke it while training for a black belt test, the doc examines my nose and X-rays (yes, it's broke). He said the nasal bone had a broken piece that was crushed inward and needed to be pushed back up into place. He then asked me if I would like to schedule a surgical procedure to set my nose or if I wanted him to go ahead and try to set it right then.

I hate to admit it but, as someone who is self-employed and carries a high-deductible on his health insurance policy, when he said "surgical procedure" I swear I heard the cha-ching of a cash register.

"Doc, if you can set it now, go ahead and do it," I said. "But you hear that 'if' loud and clear, right?"

The doctor assured me that he both heard and understood exactly what I was saying. He then shot some topical anesthetic up my nose and told me he'd be back in about 15 minutes.

Fifteen minutes later, the doctor is back and asks me if I'm ready. Like a fool, I said yes. Michael, the medical student, tells me he has a morbid excitement as he's never seen this procedure performed. In hindsight, I should have handed him my cellphone to video the next couple of minutes; I'm sure it would've gotten a million hits on YouTube.

The doc quickly puts on a glove, squirts a lubricating gel on his finger and rams his finger up my nostril, pushing on the misplaced bone fragment with all his might.

Now I know that I only had a broken nose -- not a major injury. But, trust me, having someone jam their finger up your nose, pressing on a broken bone, is a very intense experience. He literally lifted me out of the chair by my nostril. Still, that didn't work. He quickly reaches over and grabs an instrument that resembles a reinforced, stainless steel coke spoon. He jams that up my nose and starts prying on the bone piece to pop it back into place.

It was toe-curling, testicle-shrinking pain.

As this is happening, I glance at Michael and he's actually cringing!

At the very peak of the pain -- as I'm about to attack the doctor to make him stop -- the misplaced bone pops back into place. Instant relief. In fact, I felt high from the sudden relief and the huge amount of adrenaline that I'm sure was pumping in my system.

The doc then packs some gauze and antibiotic ointment in my nostril. While the doc applies a hard shield over my nose, Michael starts gushing about how he couldn't believe what he had just witnessed and he'll be telling stories about me forever. I'm so glad I could impress him.

The doc gives me a prescription for a few Tylox and some Percocet. As I checkout of the doctor's office, I joke with Michael and the office staff. In my 'sudden pain relief' state, I didn't notice that I did not receive any care or follow-up instructions. I go get the prescriptions filled and am actually feeling pretty good about now, even posting my picture via mobile upload to Facebook.

That night, however, the pain begins again. And worsens. And worsens some more. Tylox is not making a dent in the pain, but it is making me almost comatose. All Wednesday night, Thursday, and Thursday night, the pressure and pain is horrible. Almost to the pain point I felt when the doc was setting my nose. I'm thinking I have a raging infection in my sinuses and call the doctor's office. Unfortunately, I miss their return call but their message says I cannot have an infection due to the antibiotic ointment and to just continue with the painkillers.

On Friday, I call the doctor's office again, looking for an appointment with him. Instead, they say I already have an appointment scheduled for Monday and instead write a prescription for more painkillers but say I must come pick it up. After two nights without sleep and constant use of painkillers, I can barely walk around the house so I must wait until the afternoon when my wife can pick up the prescription. When she goes to the doc's office, the doc's nurse -- his normal assistant who was not there on the day I went -- tells my wife that I should continue with sinus washes. Sinus washes? I was never told anything about that.

So, while my wife was having the prescription filled, I give myself a sinus wash. An hour later, a huge plug of gauze, blood, and slime comes sliding out of my nose (sorry, no pictures). Again, the pain relief was immediate. A couple of hours later, I do another sinus rinse. And again, another plug comes out of my nostril. Now the relief is complete and the pain is gone.

On Monday, I see the doc at my appointment and he commiserates for a moment about my suffering. I told him about the sinus washes and the plugs; he nods and says the plug was probably pressing directly on my nose break. As the gauze absorbed more blood and slime, it grew and pressed all the more on the break. He apologized profusely for the lack of post-procedure instructions.

So now my nose is set and healing. In about 4-6 weeks total, I'll be able to start sparring again. Hopefully, I'll be a little more elusive when my opponent throws a big overhand right over my jab. If not, I know which of the two treatment options I'll choose.

Pain is only valuable once you know that you've learned from it. --Anonymous

And for those of you who say I should choose a more benign pasttime,

Pain is temporary. It may last a minute, or an hour, or a day, or a year, but eventually it will subside and something else will take its place. If I quit, however, it lasts forever. --Lance Armstrong

As I wrote a couple of weeks ago, I've been training hard in preparation for a black belt test scheduled for this Saturday. Thursday night, I sparred with several visiting black belts who had graciously agreed to participate in my testing. Unfortunately, one of them caught me with a punch that broke my nose.

"Yet who would have thought the old man to have had so much blood in him?" - William Shakespeare, Macbeth, 5.1

So, Friday morning I call my doctor to see about getting my nose fixed. Unfortunately, my doctor was moving his office to a new location and could not see me. So I ask the receptionist if the doctor can just refer me to an ENT specialist.

"Can you make an appointment for me at one of your practice's other locations? With another doctor?"

"No, we've already booked up all the other doctors with referrals today. You'll need to go to Urgent Care."

Instead, I decide to call my insurance company to see if I can just make an appointment directly with a specialist, cutting out the middleman as it were. Yes, it turns out I can "self-refer" to a specialist as long as they are a participating provider.

So, I call the ENT and spend the next 30 minutes arguing discussing whether my insurance will allow self-referrals or not. Finally, they call my insurance company and find that I was indeed correct.

"Our first appointment for a non-referral is December 23.", I'm told.

"That's 11 days from now! I'm self-referring; what do you mean by non-referral?"

"You don't have a referral from your doctor."

"If I had a doctor's referral when could I be seen?"

"In 3-5 days, when your swelling subsides."

Arrrggghhhh... I feel the rabbit hole open up beneath me.

I give in and go to Urgent Care. After only two hours, I'm seen by a doctor. I tell him that all I want is a referral to an ENT. He says he can't give a referral without a diagnosis and he needs X-rays to ensure I have a broken nose. He ignores me as I volunteer to ensure a broken nose by punching myself in the nose.

So, I have X-rays and, yes, my nose is broken into 3 pieces (surprising given that I don't think it's that misshapen). The doctor says he will give me a referral to an ENT. Great, I think, I'm on my way.

The staff member charged with dismissing me tells me that I'll need to take my X-rays to the ENT when I see them. So, I ask if I can just have the X-rays right then to save a trip later.

"No, you must have an appointment with a specialist before we can release your X-rays." he says with a kind of sigh that tells me the he's been down this road before.

"But they're my X-rays! Why can't I have them? And once I have an appointment with an ENT, how are you to know whether I'm telling you the truth anyway?" I argue with him.

"I know. The system is screwed up isn't it? All I can tell you is that you need an appointment first."

Whatev.

I walk out of Urgent Care and call the ENT, hoping to get an appointment and immediately pick up my X-rays. The ENT has not received the referral from Urgent Care. I'm amazed that such things aren't automated, but apparently Urgent Care usually faxes referrals. The appointment manager at the ENT tells me that Urgent Care is usually prompt with referrals and since it's now late Friday afternoon, I should call back Monday morning for an appointment.

Monday morning comes...still no referral from Urgent Care. Monday noon comes...still no referral from Urgent Care. I call them and am told that they're running behind from the weekend and will fax the referral shortly. Monday mid-afternoon comes...still no referral. I call again and ask if I can pick up the referral in person to take the ENT. Of course not.

Tuesday morning comes...still no referral from Urgent Care. Tuesday noon comes...you guessed it, still no referral. Finally, the ENT staff has pity on me, calls Urgent Care, and has the referral faxed immediately. I wish they had done this yesterday.

So now I can make an appointment with an ENT. Unfortunately, the earliest opening they have is at 3:15pm on Wednesday at their office on the other side of town. Oh, and they'll be "working me in" so I may have to wait a while. Want to bet that they look at my nose, confirm that it's broken, and schedule another appointment to fix it?

Our doubts are traitors and make us lose the good we oft might win, by fearing to attempt. --William Shakespeare

On December 20th, I am scheduled to test for a 1st dan black belt in karate. As the date approaches, I'm recalling how I used to feel every semester in college as finals approached -- a strange mixture of anticipation and dread. I'm eager to prove myself worthy of the honor, yet wondering if I'm truly up to the task.

Logically, I know that I wouldn't be invited to test if my Sensei didn't think I was ready for this challenge or worthy of the rank. And I'm confident that I know the material and can perform well. But there's still the little splinter of self-doubt that has burrowed into me, causing a bothersome worry out of proportion to its size. A single heckler plainly heard over a large audience.

When in doubt, sing loud! --Robert Merrill

So, how do I pluck the splinter and quell the doubt? All I can do is to keep training and honing my skills, while trying to keep perspective on how far I have progressed instead of dwelling on my weaknesses and shortcomings. In other words, focus on the journey traveled instead of the remaining distance. I've heard it expressed as "not thinking in the gap". When assessing your progress towards goals, focus on your progress and accomplishments instead of obsessing over the gap between your current capability and the idealized goal. Because by the simple striving for the goal, I have progressed mightily and greatly increased my capability.

Consult not your fears but your hopes and your dreams. Think not about your frustrations, but about your unfulfilled potential. Concern yourself not with what you tried and failed in, but with what it is still possible for you to do. -- Pope John XXIII

A thousand words will not leave so deep an impression as one deed. --Henrik Ibsen

Not too long ago, I was telling someone how much I enjoyed practicing a martial art -- karate, in my case. I was caught off guard a bit when they asked me why I like karate. All kinds of stream-of-consciousness thoughts and reasons ran through my head, but what came out of my mouth was "the absolute honesty of it".

People are always talking. All day, every day, people are talking about what they're going to do, what they've already done, where they've been, and how they feel about it.

Talk, talk, talk, talk, talk.

And even though people usually have good intentions, they don't always live up to their words. Even worse are the people that dramatically overstate their claims or even just outright lie.

In the martial arts, someone may talk a good game: listing their rank; detailing accomplishments in tournaments; displaying board breaking patches on their gi; naming famous instructors; even regalling with stories of real-life self-defense situations. But all that talk is just so much recherche vapor when you step onto the dojo floor. I'm still a rank beginner in the grand scheme of things, but once we start training -- especially if we're sparring --, I know literally within seconds whether you have skills or not. You cannot fake live techniques with a skilled opponent. You can either do it, or not.

My partner was recently awarded his first degree black belt in Danzan Ryu Jujitsu. In order to achieve his shodan level, he had to demonstrate his knowledge and proficiency in 160-odd techniques (throws, chokes, joint locks, etc.). While I was congratulating him, he made the comment that now he can go back and explore those techniques in more depth; he feels he has achieved a breadth of knowledge and now wants to deepen that knowledge. As a middle-aged martial artist, I appreciate the mental and philosophical aspects of the martial arts as much as the physical aspect, and Scott's comment echoed an essay I had just read by Dave Lowry in his book Moving Toward Stillness. Lowry tells the story of when he was young judoka (judo practitioner) witnessing the award ceremony for 5 new shodan black belts. Acting as one of the proctors and attending the ceremony was an extremely high ranking judo practitioner. Each of the testers congratulated the new shodans and gave bits of wisdom. Lowry recalls how he listened intently to see what words of wisdom the master would impart to the new black belts.

"You have taken a big step forward. Now, I hope you will take a big step back."

Many teaching systems use a "peel another layer" or cyclical approach to learning. Although a system may appear to be linear as students progress through a series of ranks such as belts in the martial arts or grades in school, in actuality most systems are layered and cyclical. Recall your grade school years; every year you studied the same basic subjects (the 3 R's plus history), but each year was another layer of depth and understanding. When you graduated college, you had a broad knowledge of your subject field. But you weren't an expert until you garnered a few years of real experience and had internalized the lessons learned in school. In fact, the practice of putting the lessons to work forces you to take a new view of the lessons, and provides a new perspective into their meanings and truths.

The martial arts are similar. A beginning student progresses through the ranks in a seemingly linear fashion, learning new techniques, katas, and movements. However, even though the student is eventually competent with advanced techniques, he/she is still expected to practice endless repetitions of kihon (basics). As they become more accomplished martial artists, the constant repetition of kihon leads to a deeper understanding and internalization of the art --peeling another layer.

Watch a class of beginning karateka practicing punches and you will see a group of students performing the gross motor movements necessary to perform a punch and, in fact, they may be able to throw an effective punch. Watch a group of first degree black belts performing the same techniques though and you will see a huge difference; there is no doubt that a shodan is able to throw an effective punch. While the beginner thinks at the surface layer of hitting a target with his fist, a shodan has discovered and internalized a number of layers of knowledge about the technique; solid stance, elbows in close, rotate your fist at impact, relax until the moment of impact, strongly chamber the non-striking hand, power flows up from the floor, snap the punch back, etc.

Even so, the shodan is not an expert. Achieving shodan rank is an important rite of passage but, in fact, a shodan is considered to have a thorough grounding in basic technique and ready to begin serious training. The gap between a shodan and second degree black belt (nidan) is as large as the difference between a white belt and shodan. And the difference is not so much one of breadth of knowledge as it is depth of understanding. The difference between shodans and nidans performing the same techniques is palpable, just like the difference between beginning karateka and shodans.

I suspect this pattern is prevalent in most endeavors. Most accomplished musicians probably warm up by practicing scales and basic exercises on their instruments. I imagine they compose songs in a layered fashion; revisiting the song and adding nuances with each iteration. Artists learn a breadth of techniques and mediums, and become true artists when they begin to weave their technical skill with an understanding of the interplay of light and composition. Magicians will eventually learn a huge library of tricks and will concentrate on the nuances of performance. Writers imagine a general plot, compose an outline, and develop a story through layers of drafts.

So, where am I going with this somewhat rambling post? I don't know, but I feel as if I've peeled a mental layer while writing this entry.